Nursing Home Reform in the Context of National Long‐Term Care Services and Policy: The Devil in the Details of the National Academies Report

Abstract

As the late Robert Kane pointed out, the term “nursing home” is inaccurate: most provide very little nursing, and few offer a homelike environment. No one wants to reside there until they need to, and even then, most residents wish to return to the community. The media love to malign them, they have been largely left out of Medicare and other federal financing initiatives, and their staff are paid less and given more responsibility than hospital workers. The attitude of the general public and most of the healthcare policy world is to avoid the topic. Most people do not want to contemplate becoming frail and being unable to maintain their own households; ageism may also play a role. Policymakers may not prioritize reform to the same extent as experts and advocates, given that nursing home care accounts for only 5% of national health expenditures (Centers for Medicare and Medicaid Services, 2020). Thus, it has been easy for the general public and the broader health policy community to ignore this corner of the health care delivery system. This complacency was shattered by COVID-19, which appeared to single out long-term care facilities with deadly precision. The first US setting to garner national attention because of a deadly outbreak was a nursing home (Baker and Weise, 2020; McMichael et al., 2020). During the months that followed, nearly 40% of US deaths from the virus were in nursing homes and other long-term care settings (Girvan and Roy, 2020). As the pandemic progressed and the virus spread throughout the country, that proportion gradually decreased and nursing homes achieved high vaccination rates; still, by mid-2022, the cumulative morbidity and mortality from COVID-19 in US nursing homes stood at 1,136,796 confirmed cases and 154,250 deaths among residents and 1,218,268 confirmed cases and 2500 deaths among staff (Centers for Medicare and Medicaid Services, 2022). This high rate of death in nursing homes has raised public awareness of the vulnerability of residents living in congregate settings as well as the people who care for them. Residents of such settings typically suffer from multiple chronic conditions and many from cognitive impairment, which makes isolation more difficult. Although COVID-19 may have been a catalyst for examining nursing home quality, many of the underlying factors that put nursing homes at risk, such as staffing shortages, inadequate training, and a complex financing and regulatory environment, have been at play for many years. Spurred by the severe impact of COVID-19 in nursing homes, the National Academies of Sciences, Engineering, and Medicine (NASEM) convened a committee to create a report on the quality of care in nursing homes. The committee was supported by funding from the John A. Hartford Foundation, the Commonwealth Fund, the Sephardic Foundation on Aging, the Jewish Healthcare Foundation, and the Fan Fox & Leslie R. Samuels Foundation. The committee was made up of 14 academics, two consultants, and one government official. The NASEM committee's work is also represented in several articles and an accompanying editorial in this issue. The committee was charged with examining how the U.S. delivers, finances, regulates and measures the quality of care in nursing homes. The target audience included the US Congress, the US Centers for Medicare & Medicaid Services (CMS), the US states, the nursing home industry, consumers, and other interested and involved parties. The NASEM committee hoped that similar to the 1986 study, its work would lead to significant improvement in the quality of care in nursing homes (U.S. Congress, 1987). The NASEM committee and staff worked intensively for over a year to develop a comprehensive, evidence-supported report. They conducted a thorough literature review; discussed the relevant issues and evidence at multiple meetings; heard and deliberated on presentations from three dozen leaders from industry, government, and consumer groups; and received and respo